1. Lower Urinary Tract Symptoms (includes ketamine cystitis) Dr Peggy CHU Tuen Mun Hospital

2. Lower Urinary Tract Symptoms (LUTS) Storage symptoms – Urgency, frequency, urge incontinence, nocturia Voiding symptoms – Weak or intermittent stream, straining, hesistancy, terminal dribbling or incomplete emptying Post micturition symptoms – Post micturition dribbling

3. Anatomical causes of LUTS Bladder – Overactive bladder, e.g post CVA – UTI Prostate – Benign prostatic enlargement Urethral – Urethral stricture, e.g years post gonorrhoea Urinary sphincter

4. LUTS ↑ as ages ↑ Can occur up to 30% man aged > 65 yrs ↓ QOL May point to pathology of urinary tract

5. LUTS: Initial Assessment Med Hx to identify possible causes, co- morbidities, drugs P/E: abd, genitalia, Digital rectal exam (DRE) IPSS (to allow assessment of subsequent symptom change) Freq vol chart Urine x dipstick: blood, glucose, protein, leucocytes & nitrites +/- PSA

6. LUTS: IPSS + QOL

7. LUTS: IPSS Chinese www.hkua.org

8. LUTS: QOL Chinese www.hkua.org

9. LUTS: Initial Assessment +/- PSA testing in cases of LUTS are suggestive of benign prostatic enlargement Prostate feels abn on DRE

10. Freq-vol chart

12. frequency Compulsive water drinking

13. C/O : frequency urinary incontinence

14. LUTS: when is referral necessary If LUTS Cx by Recurrent /persistent symptomatic UTI Urinary retention Renal impairment suspected to be caused by lower urinary tract dysfunction Suspected urological cancer Bordersome LUTS not responding to conservative management or drug

15. LUTS: Role of conservative Px LUTS with storage symptoms Fluid intake Lifestyle changes ( avoid coffee, tea etc) Supervised bladder training Temporary containment products ( pads)

16. LUTS: post micturition dribbling Loss of a few drops of urine after the main urine stream has finished Happens when rearranging trousers Can result in wet and stained clothing

17. LUTS: post micturition dribbling Aetiology urethra not emptied by muscles surrounding it “sump” of urine pools in urethra ↑ when ages ↑ Treatment push the last few drops of urine from the urethra with the fingers before the final shake

18. LUTS: post micturition dribbling Technique pass urine in usual manner & wait for a few sec for bladder to empty Place finger tips of hand 3 finger widths behind scrotum and press gently towards base of penis Can be repeated

19. LUTS: Drug treatment

20. Alpha blocker – Same efficacy, difference in S/E (due to difference in T ½ and uroselectivity) – Precaution in patients also taking beta blocker – Postural hypotension Anticholinergic – Avoid in closed angle glaucoma – Dry mouth, constipation

21. Ketamine Cystitis

22. Ketamine (C 13 H 16 CINO) (2-(o-Chlorophenyl)-2-(methylamino) cyclohexan-1-one Anaesthetic agent, “ dissociative anesthesia ” Rapid onset, short duration of action N-dealkylated in liver, metabolized and excreted in urine (>90%)

23. Hong Kong Statistics Central Registry of Drug Abuse 58 th Report

24. Patients TMH Sep 2006 - Jun 2010 113 patients M: F = 90: 43 mean age 25.6 yrs (14 – 42) years of ketamine abuse: 3/12 to 11 years referred by A&E, GP, psychiatrist C/O: LUTS+ve

25. Lower Urinary Tract Symptomatology frequency, urgency, dysuria, urge incontinence, painful haematuria urine culture –ve no response to multiple courses of oral antibiotics

27. Normal bladder“ketamine bladder”

28. normal bladder bladder of ketamine abuser

29. Upper Urinary Tract blood creatinine +/- hydronephrosis papillary necrosis ureteric stricture

30. Blood Creatinine 10/113 – Creatinine 126 - 1069 – 2 required PCN

32. Upper Tract Radiology all have renal USG – 30% bilateral hydronephrosis – 10% unilateral hydronephrosis

33. Pathophysiology ?chronic submucosal inflammatory response resulting from chemical cystitis ?microvascular changes ?autoimmune (raised ESR & C3/4) ?bacteriuria

34. Treatment  Antibiotics  Antimuscarinic agent (oxybutynin, detrusitol)  ? Cystoplasty   ABSTINENCE

35. New Problems with ketamine abuse

36. Guidelines (before Jun 2008)  25 g within discretion of sentencer 25 – 400 g2 - 4 yrs ’ imprisonment 400 - 800 g4 - 8 yrs  800 g  8 yrs

37. Guideline (after Jun 2008)  1 g within discretion of sentencer 1 - 10 g 2 - 4 yrs ’ imprisonment 10 - 50 g4 - 6 yrs 50 - 300 g6 - 9 yrs 300 - 600 g9 - 12 yrs 600 - 1000 g12 - 14 yrs  1000 g  14 yrs

38. Thank You